Healthcare Provider Details

I. General information

NPI: 1871045716
Provider Name (Legal Business Name): JENNIFER MARIE BURFORD FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2016
Last Update Date: 10/30/2020
Certification Date: 10/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
SAINT LOUIS MO
63104-1003
US

IV. Provider business mailing address

120 CLEAR MEADOWS DR
BALLWIN MO
63011-3852
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4110
  • Fax:
Mailing address:
  • Phone: 314-221-5620
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2016022437
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: